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Episode Transcription

Kali Dayton  0:35

Okay, I am really excited about this episode, we have been hearing from teams all over the world that are transitioning their process of care. Now that COVID has improved and there’s a little bit more bandwidth to take a deeper look at our practices.

 

But today, I’m thrilled to hear from an ECMO team that saw the needed to implement evidence based sedation and mobility practices as a life or death situation that it is, even during the height of the pandemic, their working outcomes are incredible. Be sure to check out the citations to their research on the blog for this episode at www.daytonicuconsulting.com. Jenelle, thanks for coming on the podcast. Do you mind introducing yourself to us?

 

Jenelle Sheasby, MSN, RN  1:15

Hi everyone. I’m Jenelle Shelby, I am a registered nurse, a critical care nurse. I work at Baylor Scott and White, The Heart Hospital in Plano. I’ve been there for 15-16 years now as a cvicu, nurse and kind of sort of running the ECMO program there for the past eight or nine years. But officially being the ECMO coordinator there for the last two years. I’m certified in critical care, cardiac surgery and in ECMO care.

 

Kali Dayton  1:42

Excellent. And I’m having you on today because your team put out a really exciting study, and the ACN journal. And I had this podcast all over it right. So tell us about your study how you did it and what you found?

 

Jenelle Sheasby, MSN, RN  1:58

Sure, thank you. First off for having me, we are really excited to share the results of the study. So basically, just like every other hospital in the world, and the last two years, we were sort of thrown the pandemic without really any sort of guidance or insight to how to take care of these patients to the best of our abilities.

 

And so typically, what we had done for these ARDS patients in the past is what we did was we would paralyze them, we would keep them sedated for long amounts of time, they would have really low tidal volume, really terrible compliance for their lungs. But as we kind of do knew, we knew in the background, that there was studies that show that patients who are put on ECMO, especially those who were working out for transplant and sore could be mobilized.

 

Now, this was something our facility had never done before ever. Now we’re a cardiac heavy facility. So majority, I would say 75% of our cases were of the cardiac rhythm and maybe 25% of the pulmonary realm. We had always just paralyzed, sedated, and maybe at best got a neuro vacation sedation type thing, but we would put them back back down and keep them to data for the for the most part on all of these patients.

 

What happened during the pandemic was, you know, for the first I’d say six months, we did just like we normally had done paralyzed and sedate. And then our director, our medical director, Dr. Timothy George, who was really into the research and literature out there, he kind of looked at our statistics and looked at our survival. And I think at the time, we had about 43% of patients that had survived ECMO for COVID19.

 

At that point, I think we had I don’t know, I want to say 1520 patients up to them up to that point. And he really pushed and kind of had this sort of epiphany moment and said, You know what, maybe we can just start waking them up and start mobilizing them. And when I tell you this just went off like a bomb bomb in our hospital. It was really difficult for us as nurses and everything that we knew historically on how to take care of these patients.

 

We had never had physical therapy taking care of ECMO patients before. And our nursing chief officer, Sue Craig, she actually was really a hardcore advocate saying, yes, let’s do this, let’s change our practice. Let’s, let’s follow the literature that we know about not necessarily COVID patients out there, but just patients that are on ECMO in general for respiratory failure, that mobilizing helps them.

 

And so we’re like, “Okay, let me know how that turns out.” You know what I mean, for a little while. And so we sort of did a lot of this, like kind of blindly trying to figure out how do we start to mobilize these patients? It was a lot of trial and error at first. And I think one of the biggest there was a couple of factors that were hindering us. Number one was the isolation protocols that COVID came with. In the beginning, it was a lot of what we don’t know how long we should keep them in isolation for at first it was we have to wait until there’s two negative tests.

 

I think that’s what the CDC was recommending at the time. And so that became challenging because some patients would test positive you know, three more have, you know still and so we had to keep them in isolation. And it’s very difficult to take care of anybody in isolation as we, as all nurses know. But I think another hinder too at the time was they had a really big swing in their vital signs, something that we really hadn’t seen before, it was almost like their heart rates would start to skyrocket, their blood pressure would start to skyrocket every time we would live sedation, more so than normal.

 

And we weren’t sure if this was part of the COVID disease process, if there was something, just, you know, anatomical going on there that we couldn’t figure out. But it was really difficult to stabilize their vital signs, and keep them calm as we started to wake them up. And so with those two challenges, at first, it was a struggle for the first couple of months. You know, in order to kind of do this, our nurses had to sort of band together.

 

At first, we were kind of like, No, we’re not going to do this, this is not working, you know, we kind of gave up pretty pretty, pretty quickly. And Dr. George was really good about sort of being that voice of reason. And he sort of wrote an email to the, to all of the ECMO specialists and to all of the nursing staff and said, “Thank you so much for what you guys are doing, y’all are amazing. But I really think that we need to keep going forward and keep trying this.”

 

And so it was very, we really appreciated his support of our staff and our CNO as well. And so we all just sort of, okay, let’s keep trying. So it really, it took a lot of tweaking, we figured out a few things, we figured out that precedent. Specifically, it was a good drug to help them wake up, once we started turning the propofol and paralytics off, it helped keep their heart rate a little calmer, and help keep them a little bit calmer. And we also figured out too, that when we added a lot of oral and transdermal pain medicine, antipsychotics and CO lead analytics and sort of kind of loaded them up that way, systemically, then we could turn off a lot of the heavy drips, a lot of the, you know, the fentanyl drips and all that stuff.

 

And so we were able to kind of keep them comfortable slowly, as we started to kind of turn the drips down, we also realized too, that utilizing the ECMO settings, we would when they would start waking up and having these like, kind of gasping for air type moments, we realized too, that if we slightly turned up our suite, which is the ECMO setting that blows off carbon dioxide for you, it would actually start to calm them down.

 

And we kind of figured that out during accident. And we also increased their oxygen, even though they were setting, okay, you know, low 90s, or what have you, we would just turn it up for a little while, and they would just sort of kind of kind of slowly calm down. Now a lot of the stuff I mean, there wasn’t a lot of literature research out there on that at the time. We started with just play with things until we found that sweet spot, and then we were able to wake them up, and then slowly start their rehab. And as we started to do this, you know, a few months into this. So we kind of started that in January 2021.

 

You know, by March or April, we we realized we’re like, wow, these patients are actually doing great in terms of survival. And so, you know, our longest case was 210 days that made it out, you know, alive. You know, for one, at one point, we thought she was going to need a transplant, but she ended up recovering. But, you know, in terms of just being able to recover, having that mobility, gave them an extra, you know, they hit the ground running as soon as we took them off ECMO because they had already started that rehab process, versus the ones that we kept paralyzed and sedated, who were so just a trophic.

 

I guess in terms of their musculature, they just had no sense of rehabilitation, because they were so just bed rest for so long. So deconditioned, those guys really didn’t do that great, versus the ones that we continuously rehabbed during the process of ECMO. So we kind of figured out, you know what, this is something we need to share with the world.

 

And I tell you what this is where I kind of it actually became a thought to me was, there was a conference for elso at one point, and there was this like, online thing for all of the coordinators, and a lot of patients, a lot of the coordinators, excuse me were say, how do you wait these patients because somebody did this, this sort of like, I guess, teaching seminar about mobilizing COVID ECMO? And they’re like, how do you how do you do this, like, we can’t figure out how to get our patients to wake up naturally, to wake up calmly and to be able to mobilize?

 

And so that’s when I said, You know what this needs to go out there in the world, we need to kind of show them what we figured out what we found, when we did a retrospective study of our patients, there was significant differences in the amount of drips that we use in the amounts of medicines that we use to kind of find that sweet spot for them to mobilize them.

 

Kali Dayton  9:44

So the baseline was a lot of midazolam, fentanyl, and paralytics. Right?

 

Jenelle Sheasby, MSN, RN  9:51

Correct. I would have thought that there would have been a significant difference in the propofol use because I felt like didn’t use a lot of purple fall for the awake group. But then I kind of went back and thought about it. And I realized that our propofol, we actually did use a slight not not to the point of full sedation but slight, tiny, tiny, tiny amounts for the patients that would get super, super anxious or super, super coughing.

 

And so that kind of knocked them out. So we did not find any sort of significant difference in propofol. But we did find that our patients that we basically had sedated and paralyzed, had higher amounts of verse said and fentanyl and paralytics on board. And then we were able to add precedex to those guys add the anxiolytics, the PO meds.

 

And you know what I actually was also surprised to the beta blockers, I would have, I would have bet my life that there would have been statistical difference, to show that we use beta blockers more for the ones who are awake because they woke up with such Cheka cardio and high anxiety. But there was it. And so I was really surprised about that. But I would have bet my life on that one. But we did use beta blockers to a lot of times labetalol, metoprolol, those are the two ones that we tend and Esmolol as well, we would switch between Esmolol IV and Metoprolol. I like push and or oral, but I would have thought there would have been a significant difference. But there wasn’t with that one.

 

Kali Dayton  11:18

Interesting… and how much of that tachycardia do you speculate on something physiological versus something more psychological, this and it come delirium and the discomfort that they initially had out?

 

Jenelle Sheasby, MSN, RN  11:32

For sure, I think it’s a combination of everything. I think it’s pain, anxiety all coming out. I don’t know if there’s a true physiological aspect just from the COVID itself. But we did find that just in our perspective and our findings, that that type of cardio and the high blood pressure, just now high cardiac output state would actually fight the ECMO circuit.

 

So just for those patients, people who are kind of, you know, a little bit on the not so expert side of ECMO, if you have a VV circuit, and let’s say you’re flowing at, let’s just say four liters a minute type thing, and then your cardiac output is eight liters per minute, because you’re in a high anxiety state, well, you’re only catching 50% of that blood because the heart is pushing it fast and pushing it forward. And so the ECMO can’t really keep up.

 

And so if they’re at, you know, when they’re sedated and sleeping, and if they’re at, you know, six liters a minute, while you’re catching two thirds of that, but as soon as they wake up, and they’re now jumping up to eight liters a minute, you’ve now decreased the amount of blood flow that you can catch. And so they become hypoxic, because their lungs are just garbage at this point, they they really have no lung function at all. And so everything is pretty much being supported by the ECMO circuit.

 

And so they end up having this hypoxic experience when they start waking up and get tachycardic, you know, we actually did kind of in this was really difficult for us to but we kind of allow the hypoxia a little bit, we would kind of let them as long as they were awake and kind of talking to us, we would let their SATs be in the 80s. And we would let their steps kind of dropped sometimes into the 70s, we would watch their urine output, we would watch their credit and real close, we would watch lactate levels on these guys, just to make sure that there was an overall perfusion.

 

But it was really amazing to see how much the body could handle a hypoxic state. And he’s like complete epitomes of the you know, the toughness of of COVID ECMO. I mean, we had patients with tidal volumes as low as 20 milliliters at one point, I mean, insane amounts. That mean they were like not playing anything their chest X ray looks like as white as a sheet of paper.

 

And so we just kind of just would kind of go okay, well, I mean, they’re still here, they’re still awake talking to us. And it was bizarre. I mean, we had an, of course on extremely high ECMO settings to compensate. But it was something that we had never really experienced before. And so it went out of the realm of comfort level for a lot of nurses and a lot of respiratory therapists, because they weren’t used to seeing the tidal volume of less than 50. They weren’t used to seeing a compliance number of three. I mean, it’s just it’s, it sounds so bizarre to those guys.

 

Kali Dayton  14:06

It seems counterintuitive to allow some hypoxia, correct? And how long would that hypoxia last?

 

Jenelle Sheasby, MSN, RN  14:13

That would vary, as soon as the patients would kind of start calming down. So, you know, patients would wake up, they would kind of get anxious. And, you know, when I say wake up, I mean, you know, we would let them sleep at night, and then they kind of wake up in the morning, or maybe sometimes their medicines would kind of wear off and they would have this sort of trough and their beta blockers and then their their heart rate and blood pressure will come out.

 

As soon as they kind of started calming down, then the ECMO flow would kind of kick in more and have a higher percentage of what it could catch. And then they’re hypoxic would sort of resolve so a lot of times we would just max out their ECMO settings at that point and just kind of wait it out. Very rarely did we ever have a complication, one patient did code from hypoxia, but his his saturation was as low as the 30s and he’s doing fine today. Though I can happily report.

 

But other than that, we would just kind of sit back and kind of just sit on our hands and just kind of watch it. Now, this is not something I recommend for any normal patient by any means, but in this situation really didn’t have any other choice. You know, he these patients were on ECMO, they were the sickest of the sick. And so there was really not much more that we could do for them. But yeah, for the most part, they just would come back after, you know, minutes to an hour or so.

 

Kali Dayton  15:29

Because you have these, again, like you said, the sickest of the sick patients. But what you were doing beforehand, you know, the cultural norm of prolonged paralytics, benzodiazepines, high dose opioids, immobility, we know that individually, all those things can be lethal, for sure, giving a lethal treatment to someone that’s already headed that way. And so yes, I imagine it’s so uncomfortable to Lau your patient to sit there in the 70s.

 

But how interesting that you were you had to weigh this risk versus benefit analysis, we know that the less sedation we use, the better the outcomes are, we have to we need to mobilize them, because we know that improves outcomes, but we can’t mobilize them if they’re deeply sedated. And just customizing that for each patient is fascinating and developing that skill set. So after you saw more success stories, and case studies, how did that change your team’s comfort approach expertise?

 

Jenelle Sheasby, MSN, RN  16:25

it really did. I mean, we went from people who completely doubted that we shouldn’t be doing this at all, and crying all the time watching the death and the dying. And we still, of course, had that feeling. But now it was different. Because now we got to know the patient, they were awake, they were talking to us, they were crying, they were happy, they were sad, they were laughing.

 

And so now all of a sudden, these patients in a bed had a knee now all of a sudden, they had personalities. And so it became a lot harder. And so we honestly, I almost want to say we fought a little bit harder for each one, because we got to know them almost on a personal level. Because you know, these patients, they didn’t have short runs for the most I mean, their runs are, you know, weeks to months at a time. And we watched them go through the struggles and the ups and the downs.

 

And so we would try to tell them, you know, these patients, they would cry, they’d said, these are the worst days of my life. And we’d say we know we get it, but guess what we’ve seen for other patients in your in your shoes that have made it. So we would actually bring some of those guys back to visit every once in a while and say, “Hey, I’ve been there I can, if I could do it, you can do it too.”

 

We had therapy dogs that will come and you know, the away patients got to pet those guys and sort of have therapy sessions with those because we know that it was psychologically hard on them to kind of go through that. And so as the more that we got to experience it and feel almost like experts, the more we felt like we could support them through this time.

 

Now, I did want to I forgot to say this earlier, a caveat real quick about the hypoxic, we did make sure that they had a decent h and h because we do know that the hemoglobin is the big carrier of oxygen carrying capacity. And so you know, we would not keep them to any MC we would kind of drive up there H and H to make sure that they could tolerate the hypoxia a little bit better. I did want to add.

 

Kali Dayton  18:11

Yeah, that’s that’s an important consideration. Yeah, absolutely. Just that just, I personally probably wouldn’t have thought of just allowing them to sit in the 70s for a while. Yeah. It’s if the anxiety…. if the delirium, the panic from the delirium, is causing a lot of the tachycardia and decreasing the flow through the MO, for sure if we clear out the delirium. But we help them calm down with the therapy dogs with all these other things, interaction with family communication, medications for anxiety suppressors, if we give those things some time to work, for sure.

 

Can we then watch the the saturations improve once a hurry comes down from all those little swaths of beta blockers? Right? But you have all these other things, some time to work, if we’re just fixated on a number, and we’re not looking at the big picture, that I think that’s how we end up giving lethal treatments for sure. Okay, if I just do the paralytic, this benzodiazepine, that number gets better. But then what are we actually doing? What are we working towards in the long term?

 

Jenelle Sheasby, MSN, RN  19:13

Absolutely, it was definitely a holistic approach to, you know, you know, what we actually realized, too, I don’t know what happens to the lung when they mobilize, but as they would be exerted with standing up and actually physically walking, that it almost seemed like that physical exertion actually started to help with the lungs compliance. It’s like they worked harder to breathe and they were actually sort of able to naturally versus like a positive pressure.

 

It’s like they were almost like naturally sort of, like almost popping up in their own lungs. And we know, after they started mobilizing, that their lung recovery actually came faster. And so that too, was you know, one of those things where when the patients were like, I don’t want to move I don’t want to get up, you know, maybe from depression or whatever we would try to Explain to them that this is not only just because, you know, we’re trying to be mean to you or whatever. But there’s physiological reasons behind it, why we know that mobilizing will help the recovery process.

 

And if it’s not just the acute of getting off the ECMO, yes, of course, that was always the quick goal, the short term goal, but to help get that rehab going, so that once they did come off ECMO, they would have a lot less time in rehab. And that was always the idea. But you know, we would do like the Wii with them on some of these patients. You know, they would sit up with their cannula flopping all over the place, like “Come on, play me in some tennis”.

 

You know, and so it was, it was like a camaraderie almost, with these guys going through the hardest days of their life, and they became family, they still come back all the time and visit it and, and look at that room with, you know, kind of like a PTSD type thing, but they know what they went through. And so they’re so thankful that the staff stayed with that and really supported them through that time and push them.

 

I mean, you really have to be like the army boot camp soldier, they’re saying, you know, “Let’s go get up, go, you know, I don’t wanna you don’t want them to get to, it’s great. I feel you get up, let’s go.” And so you’ve really, we would have to kind of be that bad guy. Every once in a while. Every time of course, you know, some patients did have that, that, that, you know, motivation to get up and go, but some of them didn’t. And so we had to be like, so. Yeah,

 

Kali Dayton  21:28

I wouldn’t be excited necessarily, especially if I didn’t understand why. And they’ve just already been through so much. But as a nurse, my approach was, you know, good morning, I’m Kaylee and the nurse. Do you want to walk now? Or? Now we’re in an hour? So? I mean, are you taking the first shift from for walking in the unit? Are you taking the third? Exam? For the options? Yeah,

 

Jenelle Sheasby, MSN, RN  21:51

cuz if you give them the option, yes or no, then a lot of times they picked it No, right? You’d have to say, Do you want a or b, it’s like talking to a child almost. Absolutely.

 

Kali Dayton  22:00

And I think we all respond better to options. But you do. Everyone has to understand that mobility is a life, they can enter intervention that this is essential for their ability to survive. Because it’s nurses, we don’t really get that training right in the ICU, the culture is it’s, that’s only for patients that are getting better. That’s only for patients that are younger, that’s only for you know, it’s the exception, but that should be the the norm and then those patients that cannot are the exception.

 

And I think in a few years, we’ll have more studies that will make us rethink some of our purchase the COVID-19, as far as what you’re saying is, with lung compliance improves, the lungs pop open, I don’t I don’t know how to explain it either. But I saw it, that and that we can walk in ICU, very few patients even got to the point of having to be prone and paralyzed. And it’s not because they were getting less sick patients to the ICU, that ICU with the Transfer Center was getting high Qt COVID patients to whatever ICU they could that could handle them that had beds open.

 

But yet their survival rates were totally different. They most patients can mobilize throughout their time. If they were prone, they were paralyzed. It was for shorter periods of time, just things that we don’t really have studies on to really explain why that happens. We do know that muscular atrophy can contribute to the development of ARDS, it increases the inflammation. So I there’s just so many things, but also we know that being upright moving changes, secretion, mobilization, long aeration, there’s just so many things that we don’t, we can’t really validate yet.

 

But even that even your testimonial to seeing that happen seen. I have other other podcast listeners that have said, just some anecdotal experiences where patients have come for ECMO, but they mobilize them on the bench first, and they don’t need ECMO anymore, or they’re waiting for lung transplant, and they started mobilizing them and they don’t need a lung transplant anymore. So it’s fascinating. I think there’s a huge gap in the research for that

 

Jenelle Sheasby, MSN, RN  23:56

Yes, there is. There’s a huge gap. You know, I would actually almost argue based on what we found in our study, that the patients that we mobilize actually came in sicker, believe it or not, because they were actually on significantly more vasopressors than the ones that we didn’t mobilize now.

 

There’s a couple of things that strike me as odd about that. Number one, we were in the Delta phase of the pandemic. And I do think even though there was studies to show that maybe it wasn’t in terms of even our our facility, can you did one in terms of morbidity or mortality for that, I personally think that the delta phase seem to have hit a little harder and stronger in the community, just by perception.

 

But also, it was interesting to me that because they came in a more vasopressors, that they were able to make that turnaround and survive better. All the more reason to me to just show that the mobilization was the key, you know, I would have thought, you know, for sure that the the sicker group would have been the sedated or whatever group, but it wasn’t it was actually the mobilized group that came in on higher vasopressors significantly more, and yet, they are ones that turned around and survived. So what’s the answer?

 

Kali Dayton  26:13

That’s the punchline of your study is that initially, with your baseline group, your prolonged paralytics, benzodiazepines, high opioids, your survival rate was 43%. Correct. And then this, what you’re saying is a sicker group, that you got awake and mobilized quicker? What your survival rate became 73%?

 

Jenelle Sheasby, MSN, RN  26:37

73%. Correct. That is just significant.

 

Kali Dayton  26:40

Wow. So, I know, in this podcast, we talk a lot about mortality rates. So you took your mortality rate from 57% of those COVID ECMO patients that died to then 27% mortality, correct. And you had 73% of your survivors, or of your of your COVID equo patients surviving and continuing to live their lives.

 

Jenelle Sheasby, MSN, RN  27:01

Correct. And it was actually more I would even say pleasurable for innocence for the staff to take care of them. Because they were we got to see their personalities, and we got to see them interact with their families, and we got to have those. You know, I’m doing something good in the school, not to say that the ones who are paralyzed and sedated we did and because of course we do. We know that that’s, that’s our calling, of course.

 

But it was it was more satisfying for the nursing staff to be able to participate in that. And we also I know, this is kind of a small one. But we were able to take out the Foley catheter early on a few of these patients. And so because they were awake, and so we actually were like, You know what score on that. So we were able to decrease their risk of Kati just because just because they were awake. And so again, it just plays back into that.

 

It’s a holistic approach to these patients, let’s kind of get them up. And literally, we just tried to rehab them like a normal patient and get them up with the exception of this big massive cannula coming out of their neck out to this big circuit. But we tried to treat them, you know, we took one of them outside to go have a you know, she just wanted to go outside. She had been there for so long.

 

And so we rolled her on now. And she was just looking at the sun and enjoying the weather and, you know, taking pictures and Snapchatting her friends the whole time. And you know, it’s so surreal that we could do that with these patients, versus the ones in the beginning where it was, you know, today paralyzed don’t hit the call, like the typical nurse or the ICU nurse. Right, you know. Right. Right.

 

Kali Dayton  28:31

That’s, that’s so cultural, that we think that that’s easier that that’s what we love that that makes our jobs better. Respond. But what you’re saying is so much of what I’ve experienced what I’m hearing other teams experience, I’m seeing it with the teams that I’m working with, I think we came to accept this as normal to have patients that are unresponsive, that are kind of like decaying bodies in the bed. I know that’s so callous to say.

 

But let’s be real that that is…. that’s reality of what we’ve had all throughout COVID. And I don’t think we realize how much of that weighs us down, and it contributes to the burnout, to lose that human connection. And so, your team, did you hear from your teammates? How it was impacting their trauma in their burnout?

 

Jenelle Sheasby, MSN, RN  29:17

Yes, actually, very much. So in fact, they frequently frequently talked about it, not only just the nurses but the rehab therapists they had never taken care of ECMO patients before. And so for them, this was a new experience. And we have wonderful physical therapists and occupational therapists and speech therapists and of course, our psychological experts that came in with the therapy dogs and stuff.

 

And they were like, we’ve never done this before. And so they enjoyed it too. And so for us as nurses, again, this was that you know, the peak of the pandemic or burnout was insane for everybody, not just the Heart Hospital in Plano I mean, it was for around the world. And so they truly felt like they were making a difference when the patients could actually look at them and say, “Thank you”.

 

That’s something that they couldn’t do before. And the patients in the first farm of the study, you know, they were sedated and paralyzed. But we also had most of the, I would say, majority of them in isolation, and so there was no family around. And so once again, you kind of felt like you were just treating a body in a bed, it wasn’t a person to us for a lot of reasons. And, you know, we were able to kind of put that Iron Shield down and sort of have that ability to cope with all the stress. And so you kind of turn it off mentally.

 

Whereas now that they were awake and talking to us, we felt that human aspect, and the nurses were like, Yes, I’m making a difference, I enjoy taking care of this. Now, of course, there was a few ones were like, “Ah, he’s calling again….” you know how that goes and

 

Kali Dayton  30:47

Some personalities are harder than others.

 

Jenelle Sheasby, MSN, RN  30:48

Exactly. And again, these were the hardest days of their life. And so they were not always happy, you know, little cherry blossoms of love, it was hard, you know, psychologically trying to find that sweet spot to be able to help them and, and help them cope with what they were going through, but also keep them motivated to keep working on their own rehab. It was tough, we became psychologists. In a sense, not only were we ICU nurses, but we became therapists and counselors, and we were like, What is going on here? You know, this was totally different for us.

 

Kali Dayton  31:24

But what is ironic is that in the midst of such burnout, that I would suspect that it would be hard to find that reservoir of emotion. Something more to give your team I guess, gave more emotion, you got more.

 

Jenelle Sheasby, MSN, RN  31:40

You do! It’s, it’s, you know, it’s in giving that we receive. 100%. And so it was, you know, Christmas, Christmas is coming up. And you know, you always want the gifts, right. But it’s really the happiness of giving back to others that you truly find your happiness. And I think for a lot of nurses, they found that. And so it was it was definitely something they verbalized a lot of how seeing them awake now really did help with a burnout because they could interact with them.

 

Kali Dayton  32:09

Wow. And what about the workload? Was it more work?

 

Jenelle Sheasby, MSN, RN  32:13

Yes. And yes or no, yes, in the sense of now they’re on the call, like, now they’re gonna go to the bathroom, now they gotta walk. And when I tell you, these walking sessions are not something that’s easy. I mean, we would literally half the slot, you know, a good hour, hour and a half out of our day to do this type of therapy with them.

 

Because it took coordination from respiratory therapy, the ECMO specialists, the bedside nurse, the rehab therapists, which is occupational and physical therapy, and see if the dog wanted to come to and so it would take, you know, six or seven disciplines to all get together, coordinate a time, make sure somebody doesn’t need the ECMO specialist at the, you know, because the ECMO specialists were run several cases at a time.

 

And so we have to make sure we had all the equipment and other safety checks to with the equipment of going in and out of a mobility state, we learned the hard way, you know, that if you don’t plug the gas lines back into the wall, and you keep your ECMO circuit on tank, that tanks run out. And so if you miss that crucial little tiny step, just a while the hustle and bustle of, you know, going for a walk or coming back from a walk, you could have your Yeah, bad things happen.

 

And so we came up with a safety checklist, every time you know, every tune, ECMO specialist had to do it together to make sure that all of the the T’s were crossed, and the i’s were dotted, every time that we converted from a bit mobility state to a bed rest state with the equipment. And so having said that, and you know, these, these sessions were long time in terms of planning, coordinating. And so you know, it kind of it really became something of like a song and dance, and we got really good at it. But I mean, it could be a beating in terms of the amount of workload.

 

Kali Dayton  34:00

Did it gets easier over time? I mean, we have to think through every single step is so hard.

 

Jenelle Sheasby, MSN, RN  34:05

It did, it did, it became a little bit more second nature, the more we did it, and you know, we would do several patients a day. And so we would get these really cool bandanas for the patients because they would have IGA cannulas and they would kind of go around their neck and we would secure it with bandana.

 

And so we would say we’re in a gang, and say, like, “Come on now, you know, come part of the gang” and we would all wear matching bandanas — just to make the patients feel like they were part of a gang that could walk mobilize. And so they enjoyed that too. It was just little things like that. And we wouldn’t make you know, posters in the room like, “Okay, today you walked, you know, five feet tomorrow, you’re gonna walk seven feet.”

 

And so we would, you know, make incentive type posters for those guys. And like I said, I talked about you know, we played the Wii with them several times, things that you know, if they were just sedated and paralyzed in the bed, they couldn’t appreciate or enjoy. And so it was a lot more work but it stemmed our creative senses in terms of being able to care for them in a different way.

 

That’s, you know, thinking outside the box, but it also it just enjoy on a roll and made the nurses feel more satisfaction and giving care. And it was totally worth it. And then just to see the outcomes, when we did the retrospective study, it was like, you know, like, it was amazing to see. And we were so happy to see that what we were seeing was actually coming out from a statistical standpoint, you improved survival by 30%. Yeah, it was insane. And like I said, like, not much had really changed, you know, of course, the medicines that we adjusted, but in terms of severity of illness, that remains, if anything, it was higher, and the second group coming into it,

 

Kali Dayton  35:39

and to care for them, the first way, the baseline way, “normal way”, I guess, current normal way, not the futuristic way and, or your current norm– that’s a lot of work too. It’s a lot of work either way. So why not work toward something that actually works?

 

Jenelle Sheasby, MSN, RN  35:53

Absolutely. Now the isolation was a lot of work that we had to put them through in the beginning, but just maintaining all the drips and trying to keep their vitals you know, stable and stuff, that’s a lot of work to for nurses just to be able to, you know, titrate, you know, these this presser and this paralytic and this sedative, and, you know, keeping up with all those drugs, and it’s a lot of work as well.

 

And so, then you have the whole, you know, once they come off the ECMO, then you have to worry about the rehab starting and then that just pushes back that time even further, which versus the ones that we rehab through the ECMO run. And then, you know, once they came off, they were ready to go to rehab. Like it wasn’t like a long term in the hospital afterwards. It was really, really short actually.

 

Kali Dayton  36:38

Did you also look at the time on the ECMO time, the ICU time, the hospital discharge disposition?

 

Jenelle Sheasby, MSN, RN  36:43

We did we looked at the days on ECMO, and there was not a statistical difference. So they they seem to, I think, I want to say it was like an average, I can’t I can’t remember the numbers, but there wasn’t a statistical difference in terms of the amount of time that they were actually on ECMO, I would have thought that maybe they would have come off quicker mobilizing it, but they really didn’t. So I’m not sure. And then I think the length of stay.

 

I don’t think there was a difference on that one as well. But, you know, cannula repositioning became a problem. I do have to say that, you know, in terms of more work, there was a lot of patients and not again, going back to people who aren’t very familiar with ECMO in general, when you have a cannula through the IJ, like we did for most of our we did have a few subclavian approaches, but for the most part we did ij the amount of turning the cannula Kenny adjust the amount of flow inside the body and the amount of effectiveness of the ECMO circuit flow.

 

And so if they’re, if your cannula is now positioned, well, the patient doesn’t get as much good ECMO flow as they should, and they can end up getting hypoxic. And so in order to fix that, we’d have to get an echo. And so the physician would be at the bedside adjusting the cannula to make sure that it’s facing the right way inside the heart chamber.

 

But for the patients who are paralyzed and sedated, well, there wasn’t a lot of movement really had to do at one time. But for the patients who are mobilizing, as you can imagine they’re moving their head around, they’re, you know, they’re leaning left and leaning right. And so the cane line gets all wonky inside. We statistically had to adjust that cannula way more times for those guys to be expected. This was one of the drawbacks. We knew it.

 

But it was something that the specialists had to really monitor and watch for and say, “Oh, my patients re-circulating. I think we need to do an echo to see if the cannula is maladjusted. And most of the time they were.”

 

Kali Dayton  38:39

So do you think there’s room for development of securement devices that could mitigate?

 

Jenelle Sheasby, MSN, RN  38:43

Yes. And in fact, I think one of our tour nurses was looking into that for one of her DNP studies. She’s like, Okay, that’s it, I’m going for it. And so we’ll have to keep you posted on that and see if she ever figures something out. But there are some security devices, we tried a few quite stick as well as we were thought or hoped for.

 

So that’s why we kind of got creative with the bandana approach and just kind of put a lot of H wrap and all that and a little bit down on top of it just to kind of keep them as much as possible. You know, you one of the guys kind of got a little confused and started pulling out the cannula and you kind of yanked it out a little bit.

 

So you do have to kind of watch these patients in terms of safety as well. It’s not you know, you have to kind of they’re gonna they can have some delirium too, you know, even though they’re awake and stuff, they wake up and not realize where they are sometimes and they’ll go for that cannula. So you have to kind of keep a close eye on it.

 

Kali Dayton  39:36

That was my question too, because you’re bracing patients that have probably been sedated. Yes, mobilize for, in general, how long?

 

Jenelle Sheasby, MSN, RN  39:44

It kind of varies. It depends on on how many beds we had available in the hospital. And so if you know we would get a call about them. Sometimes it would only be like two to three days that they had been paralyzed and sedated. But sometimes we had a waitlist at the time because we were running at seven or eight ECMOs.

 

So we didn’t have the bed capacity, just like all the rest of the world in terms of, you know, everybody being full all the time. And so, you know, they would probably be, you know, a week, maybe sometimes a little bit longer of sedation and paralytics.

 

But we try not to push it past 10 days of sedated and paralyzed because we just know, statistically, just from other studies in the past, and what ELSA recommends that you don’t want to have Max vet settings and paralytics past that time, because at that point, ECMO may not do that much for you in terms of recovery. So if they were past 10 days, we would probably not take them, but that average, I would say was probably two to three to four days that they had been paralyzed and sedated.

 

Kali Dayton  40:47

And with your previous norm, how are you able to screen delirium? Do you feel like that was a focus? I think there was awareness? Or were you able to screen for it?

 

Jenelle Sheasby, MSN, RN  40:57

It was different, it was very difficult. I don’t think we could, to be honest. You know, the, with the isolation, you know, nurses really did not go into the rooms too often. As little as possible, I’d say, and then just being sedated and paralyzed, it was difficult to get a true assessment of that. And so I would say we probably failed on that perspective. Unfortunately.

 

Kali Dayton  41:20

Then when you you started waking patients up, did you see a lot of delirium initially?

 

Jenelle Sheasby, MSN, RN  41:24

Yes. On some, yes. An unknown? No, for sure. You know, they’re, I would say, maybe a quarter of them would have these moments where and, you know, it could have been hypoxia, it could have been, you know, the side effects of some of the anti-psychotics and analytics that we were giving them. I mean, it could have been a side effect of a whole lot of things just not sleeping very well, you know, it could have been a side effect of all kinds of stuff.

 

And so there was some that we would definitely, and we have our palliative care team, which was really great, who would always try to adjust their meds and anti-psychotics as much as possible to try to keep that, you know, under control. And then we would also make sure that we staff, our patients for ECMO, one to one in terms of nursing care, and then we have an ECMO specialists that will run up to three or four circuits at a time.

 

So they were always one on one care with a nurse, an ICU nurse. So it was almost like they had a personal sitter at all times, just to make sure that they didn’t, you know, pull out anything or, or what have you. But it did happen on occasion, one fortunately,

 

Kali Dayton  42:26

yeah, I mean, it’s, it can be just part of the critical illness.

 

Jenelle Sheasby, MSN, RN  42:30

It was just part of the illness. But and, you know, all of those patients today to this day are perfectly fine. And I know that because I’ve kept in touch with every single one. We actually had a big ceremony last year in honor of our physician, our medical director, and he got doctor of the Year Award, which he completely deserved. And we brought a lot of those patients back.

 

And it was about 15 or so of them, and they came up on stage, and they all hugged him and thanked him. And so they’re living normal lives. And I mean, these patients you wouldn’t even recognize because, I mean, what they had gone through, they had lost so much weight during the COVID time, and you know, they, they were crippling around, but now they’ve been to rehab and they’re, you know, full and great. And, and, and life is great for them.

 

And they’re celebrating their children’s weddings, and they’re celebrating graduations. And so they’re, it’s really it was wonderful to see that to see them all doing really well. But yeah, and we’re gonna actually be doing a study on them. Coming up, we are doing a study to see what do their ABGs look like today, what did their pulmonary function tests look like today? What type and we’re gonna give them a quality of life screening? So they can fill that out? And let us know, because we don’t have a lot of information on long term coming off of COVID ECMO?

 

Kali Dayton  43:43

Will you also use some of the baseline data or some of those initial survivors as well?

 

Jenelle Sheasby, MSN, RN  43:48

Yes, that’s what we’re going to try to have it. We have that study coming up, we got approved by our research, governance. And so we’re really excited. I just called them all a couple months ago, and I gave them a heads up this study was ongoing. And so they’re like, yes, and so I would say a good 15 to 20 of them. So yes, I want to participate in a few didn’t really care to or didn’t answer. But But yeah, we were really excited. So

 

Kali Dayton  44:11

oh, that’s incredible. And the fact that they were coming back to thank Dr. George yes for for changing the culture that allowed them to be awakened mobile. There’s this new anything time I posted something on social media, there are always comments, voices, saying that’s inhumane, that’s unsafe. If I was a patient, I’d want to be completely knocked out the entire time.

 

But those that have actually lived it. Yeah. They don’t deny that it was uncomfortable that it was scary, but they they find so much value and being present during that experience fighting for their own lives, making those connections with the staff being with their families, but then especially being able to resume quality of life

 

Jenelle Sheasby, MSN, RN  44:48

after correct and I think that’s where a lot of them really appreciate having that rehab. I would imagine it I would assume that now I didn’t we didn’t actually look at the actual stats on it. But the math ount of rehabilitation time that it took afterwards, I mean, for the most part was was a lot easier and quicker.

 

I, you know, one of the other benefits too, is that they got to interact with their families. And a lot of them they realize, you know, when you take your vow with your spouse, it’s for better or for worse, for sicker, you know, for unhealthiness, and, and sickness. And I think they realized, you know, what, my spouse stayed with me through this, “I am so blessed and grateful.” And so many of them have actually said that, to me, they’re like, “I didn’t realize I had the best spouse in the world until I went through this.”

 

And so I really, they, they felt a lot of appreciation for what their families stuck with them. Because again, this was weeks months that they had to endure this. And so it was it was from a human perspective, it was really amazing to watch that they got to be there with their families.

 

Kali Dayton  45:52

When ARDS survivor, Brian Carter that I interviewed at the beginning of the podcast, he said that he wasn’t sure how his wife could have endured that experience, if he hadn’t been present with her. They were mutually supporting each other. And she didn’t have to be born with all the decisions, she asked. But she also got to ask him questions, be assured that he was okay.

 

Deciding together, it was, I hadn’t really appreciated that aspect of the support that the family members get from the patients and vice versa. Absolutely. I heard from survivors himself.

 

Jenelle Sheasby, MSN, RN  46:24

Absolutely. We had a few where, you know, let’s just say it was like a male in the bed, and the wife would come and be like, how do I drain the pool? Or how do I do this? You know, what I mean? Like, you know, things around the house that the male had taken care of, for so long, you know, you’d be like, “Well, you gotta go over here. And you have to do this.” And so they were, you know, ask, “What’s your password for your, you know, bank account, I gotta pay this bill, you won’t even know when to pay it.”

 

And so, again, like you said, they were interacting, and they got to mutually make decisions about things. And you know, when the day is when the patient didn’t want to move or something, that spouse would be right there and say, Get up, you know, I want you home with me. And so they’d be like, maybe not. Now, just kidding, but know that and so they would say, yes, you know, this is why this is what I’m I have for that, that end goal, right there is to be home with my spouse, I can’t wait and or my children, or, you know, my family in general. And so, it was almost like, mind over matter.

 

For a lot of these patients, they got to see the end goal, whereas the ones who were kind of sick and in the bed that didn’t have that privilege, and so we sort of dangle that carrot on the stick for those guys that were awake, and it became an issue is the ability of that psychological, you know, grit to be able to push through.

 

Kali Dayton  47:40

So, no, I think that’s another gap in the research that there’s a way to measure with will to live. Yeah, and the impact that has on survival. That would be fascinating. But I see that it’s simplified in those kind of scenarios that you’re talking about. And so now, your IC doesn’t have something COVID patients, but what is your culture and practice for ECMO patients now.

 

Jenelle Sheasby, MSN, RN  48:02

So in general, now, even for not so much the cardiogenic shock ones, because they seem to be a lot more immobile in terms of well, you know, a lot of them, we have unloading devices and venting devices, like a balloon pump, or just a ventricular assist device, just to kind of help.

 

And so, it for those guys, we haven’t really mobilized much for our cardiogenic ones. But for our pulmonary ones that we’ve gotten, not specifically COVID, but just in general, you know, like a good strong, you know, ARDS patient that we actually did have recently, you know, we mobilize them now. And so it becomes a part of our culture. And so we take them early, we get them up, start moving around.

 

So I think, you know, it’s definitely changed us in the way that we take care of ECMO patients for now and in the future, not just COVID, but all of them in the future. And we are thinking about the idea and toying with the idea for cardiogenic patients, for the ones that were stable, you know, the ones that are not say, well, obviously not, but the ones that are stable enough, we have extubated a few we haven’t quite in, I know there’s a lot of research out there about mobilizing the femoral, the cannulated VA cases. We haven’t quite embarked on that yet. But we have had him awake eating and things like that. So we’re getting there one step at a time.

 

Kali Dayton  49:17

And the clever thing about this movement, I would say is that those that have done it are so excited to share. So I have some experts that have mobilized the femoral cannulated, the LVAD all the things they could be great research sources for your team. And I obviously your team has a lot to share with the rest of the community. So I will keep everyone in touch. I’ll have a study on the blog as well as a transcription of this podcast. Any other studies that you are in love with? Let’s share that for everyone. That’s everyone’s homework after this episode, thank you so much denial for everything that within your team, but also sharing it with the community. The impact is immeasurable. Thank you so much.

 

Jenelle Sheasby, MSN, RN  49:54

Thank you so much for letting us appreciate it.

 

Transcribed by https://otter.ai

 

References

An Interprofessional Approach to Mobilizing Patients With COVID-19 Receiving Extracorporeal Membrane Oxygenation

 

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